[Hiring] Medical Review Nurse @Peraton

Role Description

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse. We are looking to add a Nurse Reviewer to our SGS team of talented professionals.

What you'll do:

• Conduct medical record reviews and apply sound clinical judgment to claim payment decisions.
• Perform additional research on medical claims data and other sources of information to identify problems.
• Review sophisticated data model output and utilize a variety of tools to detect potential fraud.
• Support ongoing fraud investigations and requests for information.
• Identify and develop cases for future administrative action, including referral to law enforcement and overpayment recovery.
• Work with external agencies to develop cases and corrective actions.
• Respond to requests for data and support.
• Present issues of concern, citing regulatory violations and alleging schemes or scams to defraud the Government.
• Research regulations and cite violations.
• Conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers.
• Make claim payment decisions based on clinical knowledge.
• Telework available from anywhere in the United States.

Qualifications

• 5 years experience with BS/BA.
• Experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity.
• Current nursing license.
• Strong investigative skills.
• Strong communication and organization skills.
• Strong PC knowledge and skills.
• U.S. citizenship required.

Requirements

• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases.
• Have a CPC (Certified Professional Coder) certificate.

Essential Functions

• May require the incumbent to appear in court to testify about work findings.
• Ability to compose correspondence, reports, and referral summary letters.
• Ability to communicate effectively, internally and externally.
• Ability to handle confidential material.
• Ability to report work activity on a timely basis.
• Ability to work independently and as a member of a team to deliver high quality work.
• Ability to attend meetings, training, and conferences; overnight travel required.

Target Salary Range

$51,000 - $82,000. This represents the typical salary range for this position. Salary is determined by various factors, including but not limited to, the scope and responsibilities of the position, the individual’s experience, education, knowledge, skills, and competencies, as well as geographic location and business and contract considerations. Depending on the position, employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay.

Benefits

• Medical, dental, vision, life insurance.
• Health savings account.
• Short/long term disability.
• Employee Assistance Program (EAP).
• Parental leave.
• 401(k).
• Paid time off (PTO) for vacation.
• Company paid holidays.

Application Statements

The application period for the job is estimated to be 30 days from the job posting date. However, this timeline may be shortened or extended depending on business needs and the availability of qualified candidates. By applying to this job, you are expressing interest in the role and the Company. During the review of your application, you may be required to participate in an on-camera interview, as well as participate in a process to verify your identity. Use of artificial intelligence (AI) tools of any kind during Peraton interviews is strictly prohibited unless the candidate has obtained prior written authorization. All interview responses must be the candidate’s own.

EEO

EEO: Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.